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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOEOFFICE USE: ' Z601 E. Hazelton Ave:, Stockton, Calif. <br /> " Telephone: (209) 466-678 . <br /> ATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_$7 4J <br /> THIS PERMIT EXPIRES i YEAR- FROM DATE ISSUED Date Issued /0.-11-7-- <br /> j&Ti; S c.a 'e") C-*4-rnE�.. �E, (Complete,In:Triplicate) � 1-7-9 ,- d`�—L`- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein_ described. This application is made in compliance with .San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOC TIQP kp ® ` ��� CENSUS TRACT _ <br /> Owner P s Name �U;7__ Phoneme! <br /> Address �, <br /> �'"' ' ),j I- City a <br /> � L �1 License 4f4?373 Phone a4 6cf� <br /> Contractors Name _ - -• <br /> TYPE OF WORK (Check): NEW WELL DEEPEN':/_7 RECONDITION DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR / /PUMP REPLACEMENT . � <br /> / <br /> Other %// ._ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ ' CESSPOOL/SEEPAGE PIT . OTHER =, <br /> PROPERTY LINE - PRIVATE DOMESTIG-WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE ;•;y t TYPE OF WELL ) r,)CONSTRUCTION SPECIFICAT NS.w <br /> Industrial +- Cable Tool Dia. of Well,Excavation <br /> Domestic/private '`' DrilledDia. of Weil?Casing <br /> Domestic/public �- Driven � Gauge of Casing Ww � <br /> Irrigation Gravel Pack Depth of Grout Se <br /> Cathodic Protection , Rotary Type of Grout <br /> Disposal <br /> Other Other Information = - <br /> Geophysical *� _,.. Surface Seal Installed By.:- <br /> ` <br /> PUMP INSTALLATION: Contractor iN: <br /> H.P. <br /> Type of Pump <br /> J <br /> tate Work Done <br /> PUMP REPLACEMENT: / / S <br /> 4 y <br /> f � <br />#,_-PUMP,':REPAT•R: /L�&;,State-Work-Done <br /> PES;TRUCTION OF WELL': Well Diameter Approximate Depth <br />' - Describe Material and Procedure <br /> k; I hereby agree to comply with all laws and regulations of the San Joaquin. Local Health District <br /> and the State of California pertaining to or .regulating well construction. Within FIFTEENf.DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the. well 'in.use.. The above <br /> information is true to the-best of my knowledge and belief. 1 WILL CALL F'OR"A GROUT INSPECTION <br /> PRIOR TO .GROUTING AND A FINAL INSPECTION. �` <br /> SIGNED �- 4 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> t APPLICATION ACCEPTED BY C�Wfi&=::t <br /> J. ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE j � - INSPECTION BY DATE - u <br /> ;~fir <br /> ' 1-74,.2M <br /> H 1k26 Rev. 1--74 �° <br />